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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1'601'E3�HAZELTON AVE.,STOCKTON, CA TelephoW(209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete)n Tripljcate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District:, ti,' p � Job Address ! L City Lot Size 9y0 PM T1=7iJ14/t� Address Owner's Name ffJ. �llJ.✓14Phon� Contractor;; �`` `�` "T Q�� _ . _ Address.__.��r�.__.�..tl..�...-....,..�...:..,-,....�...»H+tftse Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ii ; DISTANCE TO;NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial. t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic'/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public j ❑ Other ❑ Delta Depth of Grout Seal Type of Grout O j ❑ Irrigation, �• I ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ 't k f^1f i � Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION XREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will-serve: Residence-%, - Commercial_ Other Number of living units:_,L_ Number of bedrooms --3 Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK4 g Type/MfgCapacity. 6 Z No. Compartments j PKG. TREATMENT PLT. F1 .. C , Method of Disposal t • $ _ _ � 1 Distance to nearest: Well ,Foundation Property Line Acca it f + LEACHING¢LINE No. Length oif lines '�-�x,95».e�7E7�`�_ Total length/size 5- J+7d ( 3 FILTEROBEDe ❑ Distance to nearest: Well X 5a Foundation �r 7� t "` � Property Line � r SEEPAGE PITS ❑ Depth Size Number [1 SUMPS 4� Distance to nearest: Well Foundation Property Line DISPOSAL.POND ! w:,rl] •� t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and•., rules and regulations of the San Joaquin Local Health District.-1 Z; Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I, all not employ any person'in<s66h'riianner'as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that.in'the performance of the work for which this permit is issued,I shall employ persons subject to workmen's compensa- tion laws of eCafrforriia:"`''`'• The applicant mus c all required s ns.�Corn'J drawing on reverse side. Signed i § .-Title: Date:Date: '- *� --�-�• it `� FOR.DEPARTMENT USE ONLY1, 1 ( 1 r Application Acceptedby _ Date Area v .Pit or Grout Inspection by Final-:Inspection by tel/Y ... Date Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104'k- tib,❑Tracy 1835-fi38ta I Applicant -:Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE < INFO AMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE PERMIT''NO. + EH 13-24IRE%s/a5! fJ � EH 14-28 f f